ATR15-150929-01GC (09/28/2015) 1

This Insurance is effected with Certain Underwriters at Lloyd’s, London.

This Certificate is issued in accordance with the limited authorization granted to the

Correspondent by Certain Underwriters at Lloyd’s, London whose syndicate numbers and the

proportions underwritten by them can be ascertained from the office of the said Correspondent (such

Underwriters being hereinafter called “Underwriters”) and in consideration of the premium specified

herein, Underwriters hereby bind themselves severally and not jointly, each for his own part and not

one for another, their Executors and Administrators.

The Assured is requested to read this Certificate, and if it is not correct, return it immediately

to the Correspondent for appropriate alteration.

All inquiries regarding this Certificate should be addressed to the following Correspondent:

303 Congressional Boulevard

Carmel, IN 46032

1-800-335-0611

317-575-2652

317-575-2659 FAX

www.sevencorners.com

Lloyd’s Certificate

ATR15-150929-01GC (09/28/2015) 2

CERTIFICATE PROVISIONS

1. Signature Required. This Certificate shall not be valid unless signed by the Correspondent on the attached Declaration Page. 2. Correspondent Not Insurer. The Correspondent is not an Insurer hereunder and neither is nor shall be liable for any loss or claim whatsoever. The Insurers hereunder are those Underwriters at Lloyd’s, London whose syndicate numbers can be ascertained as hereinbefore set forth. As used in this Certificate “Underwriters” shall be deemed to include incorporated as well as unincorporated persons or entities that are Underwriters at Lloyd’s, London. 3. Cancellation. If this Certificate provides for cancellation and this Certificate is cancelled after the inception date, earned premium must be paid for the time the insurance has been in force. 4. Service of Suit. It is agreed that in the event of the failure of Underwriters to pay any amount claimed to be due hereunder, Underwriters, at the request of the Assured, will submit to the jurisdiction of a Court of competent jurisdiction within the United States. Nothing in this Clause constitutes or should be understood to constitute a waiver of Underwriters’ rights to commence an action in any Court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a transfer of a case to another Court as permitted by the laws of the United States or of any State in the United States. It is further agreed that service of process in such suit may be made upon Mendes and Mount; 750 Seventh Avenue; New York, NY 10019-6829 USA (For California residents, contact Eileen Ridley, FLWA Service Corp., c/o Foley & Lardner LLP, 555 California Street, Suite 1700, San Francisco, CA 94104-1520 USA.), and that in any suit instituted against any one of them upon this contract, Underwriters will abide by the final decision of such Court or of any Appellate Court in the event of an appeal. The above-named are authorized and directed to accept service of process on behalf of Underwriters in any such suit and/or upon request of the Assured to give a written undertaking to the Assured that they will enter a general appearance upon Underwriters’ behalf in the event such a suit shall be instituted. Further, pursuant to any statute of any state, territory or district of the United States which makes provision therefor, Underwriters hereby designate the Superintendent, Commissioner or Director of Insurance or other officer specified for that purpose in the statute, or his successors in office, as their true and lawful attorney upon whom may be served any lawful process in any action, suit or proceeding instituted by or on behalf of the Assured or any beneficiary hereunder arising out of this contract of insurance, and hereby designate the above-mentioned as the person to whom the said officer is authorized to mail such process or a true copy thereof. 5. Assignment. This Certificate shall not be assigned either in whole or in part without the written consent of the Correspondent endorsed hereon. 6. Attached Conditions Incorporated. This Certificate is made and accepted subject to all the provisions, conditions and warranties set forth herein, attached or endorsed, all of which are to be considered as incorporated herein. 7. Short Rate Cancellation. If the attached provisions provide for cancellation, the table below will be used to calculate the short rate proportion of the premium when applicable under the terms of cancellation.

Short Rate Cancellation Table for Term of Three Hundred And Sixty-four (364) Days.

Days Insurance In Force

Percent of Coverage Period Premium

Days Insurance In Force

Percent of Coverage Period Premium

Days Insurance In Force

Percent of Coverage Period Premium

Days Insurance In Force

Percent of Coverage Period Premium

1........................................5 % 2........................................6 3 - 4........................................7 5 - 6........................................8 7 - 8........................................9 9 - 10..................................... 10 11- 12..................................... 11 13- 14..................................... 12 15- 16..................................... 13 17- 18..................................... 14 19- 20..................................... 15 21- 22..................................... 16 23- 25..................................... 17 26- 29..................................... 18 30-32 (1 mo.) ......................... 19 33- 36..................................... 20 37- 40..................................... 21 41- 43..................................... 22 44- 47..................................... 23 48- 51..................................... 24 52- 54..................................... 25 55- 58..................................... 26 59-62 (2 mos.) ....................... 27 63- 65..................................... 28

66 - 69 ................................... 29 % 70 - 73 ................................... 30 74 - 76 ................................... 31 77 - 80 ................................... 32 81 - 83 ................................... 33 84 - 87 ................................... 34 88- 91 (3 mos.) ...................... 35 92 - 94 ................................... 36 95 - 98 ................................... 37 99 - 102 .................................. 38 103 - 105 ................................ 39 106 - 109 ................................ 40 110 - 113 ................................ 41 114 - 116 ................................ 42 117 - 120 ................................ 43 121-124 (4 mos.) ................... 44 125 - 127 ................................ 45 128 - 131 ................................ 46 132 - 135 ................................ 47 136 - 138 ................................ 48 139 - 142 ................................ 49 143 - 146 ................................ 50 147 - 149 ................................ 51 150-153 (5 mos.) ................... 52

154 - 156……………………...53% 157 - 160 ............................... 54 161 - 164 ............................... 55 165 - 167 ............................... 56 168 - 171 ............................... 57 172 - 175 ............................... 58 176 - 178 ............................... 59 179 -182 (6 mos.) .................. 60 183 - 187 ............................... 61 188 - 191 ............................... 62 192 - 196 ............................... 63 197 - 200 ............................... 64 201 - 205 ............................... 65 206 - 209 ............................... 66 210 - 214 ............................... 67 215 - 218 ............................... 68 219 - 223 ............................... 69 224 - 228 ............................... 70 229 - 232 ............................... 71 233 - 237 ............................... 72 238 - 241 ............................... 73 242-246 (8 mos.) .................. 74 247 - 250 ............................... 75 251 - 255 ............................... 76

256 - 260…………………….77% 261 - 264 ................................ 78 265 - 269 ................................ 79 270-273 .................................. 80 274 - 278 ................................ 81 279 - 282 ................................ 82 283 - 287 ................................ 83 288 - 291- .............................. 84 292 - 296- .............................. 85 297 – 301 ............................... 86 302–305 (10 mos.) ................ 87 306 - 310 ................................ 88 311 - 314 ................................ 89 315 - 319 ................................ 90 320 - 323 ................................ 91 324 - 328 ................................ 92 329 - 332 ................................ 93 333-337 (11 mos.) ................. 94 338 - 342 ................................ 95 343 - 346 ................................ 96 347 - 351 ................................ 97 352 - 355 ................................ 98 356 - 360 ................................ 99 361-364……............………..100

Rules applicable to insurance with terms less than or more than three hundred and sixty-four (364) days: A. If insurance has been in force for three hundred and sixty-four (364) days or less, apply the short rate table for three hundred and sixty-four (364)

days of insurance to the full Coverage Period premium determined as for insurance written for a term of three hundred and sixty-four (364) days. B. If insurance has been in force for more than three hundred and sixty-four (364) days:

1. Determine full Coverage Period premium as for insurance written for a term of three hundred and sixty-four (364) days. 2. Deduct such premium from the full insurance premium, and on the remainder calculate the pro rata earned premium on the basis of the

ratio of the length of time beyond three hundred and sixty-four (364) days the insurance has been in force to the length of time beyond three hundred and sixty-four (364) days for which the policy was originally written.

3. Add premium produced in accordance with items (1) and (2) to obtain earned premium during full period insurance has been in force.

ATR15-150929-01GC (09/28/2015) 3

Insurance is effective with CERTAIN UNDERWRITERS AT LLOYD’S, LONDON. The Binding Authority Reference Number is B0572NA15SC04

IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS CERTIFICATE, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS CERTIFICATE.

THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. International Major Medical Coverage: A Coverage Period is 364 days in length.

Coverage Period Premiums

Ages

Deductibles

$1,000 $1,500 $2,500 $5,000 $10,000

60 $11.87 $10.22 $8.37 $6.89 $6.56

61 $12.10 $10.42 $8.67 $7.02 $6.76

62 $12.23 $10.75 $8.77 $7.19 $6.82

63 $12.46 $10.85 $9.00 $7.32 $6.96

64 $12.66 $11.18 $9.30 $7.48 $7.05

65 $12.86 $11.24 $9.46 $7.75 $7.19

66 $13.42 $11.67 $9.79 $7.95 $7.38

67 $14.01 $12.10 $10.05 $8.27 $7.62

68 $14.60 $12.66 $10.29 $8.60 $7.78

69 $15.13 $13.15 $10.58 $8.77 $8.04

70 $15.76 $13.71 $10.85 $9.03 $8.21

71 $16.32 $14.01 $11.27 $9.49 $8.47

72 $16.98 $14.64 $11.87 $9.79 $8.70

73 $17.57 $15.03 $12.20 $10.12 $8.93

74 $18.03 $15.36 $12.76 $10.55 $9.16

75 N/A $15.96 $13.19 $10.81 $9.63

76 N/A $16.48 $13.71 $11.21 $9.99

77 N/A $16.81 $14.01 $11.54 $10.12

78 N/A $17.31 $14.54 $11.80 $10.42

79 N/A $17.80 $14.93 $12.16 $10.65

80 N/A N/A $15.49 $12.40 $10.98

81 N/A N/A $16.35 $13.68 $11.87

82 N/A N/A $17.14 $15.16 $12.99

83 N/A N/A $18.03 $16.65 $14.01

84 N/A N/A $18.69 $18.00 $15.10

85 N/A N/A N/A $19.45 $16.25

CERTIFICATE OF INSURANCE DECLARATIONS

Green Cover ATR15-150929-01G

This Declaration is attached to and forms part of certificate provisions

ITEM 1. NAMED INSURED AND MAILING ADDRESS

Green Cover World Commercial Trust Tortola, British Virgin Islands

ITEM 2. POLICY PERIOD FROM: TBD TO: TBD TERM: 364 days

X 12:01 A.M., North American Eastern Time

ATR15-150929-01GC (09/28/2015) 4

This certificate of Insurance is made and accepted subject to the foregoing stipulations and conditions together with such other provisions, agreement or conditions as may be endorsed or added here to.

Dated: 10/01/2015 By:________________________________________ (Correspondent – James J. Krampen, Jr.)

86 N/A N/A N/A $20.87 $17.34

87 N/A N/A N/A $22.29 $18.46

88 N/A N/A N/A $23.60 $19.55

89 N/A N/A N/A $25.02 $20.67

90 N/A N/A N/A N/A $21.86

91 N/A N/A N/A N/A $22.98

92 N/A N/A N/A N/A $24.07

93 N/A N/A N/A N/A $25.19

94 N/A N/A N/A N/A $26.27

95 N/A N/A N/A N/A $27.40

The premiums above include a 2% Trust fee For Part A coverage only multiply the above rate by .60 For Part B coverage only multiply the above rate by .60 Mode Premium shown above, payable: Daily in Advance Surplus Lines Agent: James J. Krampen, Jr. Surplus Lines Agent License #: 2845819 Surplus Lines Agent Address: 303 Congressional Blvd. Carmel, IN 46032

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Certificate of Insurance Underwritten by:

Certain Underwriters at Lloyd’s, London

Hospital and Doctor Network: To locate a network facility in the United States, search online at www.sevencorners.com/networkproviders, contact Seven Corners Assist at the numbers shown below, or log onto WellAbroad.com. Pre-certification: Please see the Pre-certification section for details and requirements regarding pre-certification and use of the network. Please note the 50% penalty for failure to pre-certify. You are strongly encouraged to review these requirements. Pre-certification does not guarantee benefits nor does use of the network. Claims – It is important to submit Your claims to Seven Corners quickly. To be considered, all claims must be submitted to the Seven Corners Claim Department within 90 days after the date of service. Travel Assistance - To receive assistance, call Seven Corners Assist at the numbers below and provide them with Your ID Number. Seven Corners Assist - In the United States (Toll-free): 1-800-690-6295 or Collect Calls: 0-317-818-2808 Email: assist@sevencorners.com

SCHEDULE OF BENEFITS: All Coverages and Plan Costs listed in this Evidence of Benefits are in U.S. Dollar amounts.

Medical Maximum Ages 60-74: $250,000 Ages 75-79: $100,000 Ages 80-89: $50,000 Ages 90-95: $25,000

Deductible $1,000; $1,500; $2,500; $5,000; $10,000

Coinsurance After You pay the Deductible, the plan pays 80% of the next $10,000 of eligible expenses, then 100% to the selected Medical Maximum.

Dental (Accident Coverage) To a maximum of $500 (Only available to programs purchased for 1 month or more.)

International Travel Coverage

Ages 60-74: $5,000 Ages 75-95: $2,500

Assistance Services Included

Part A Coverage

Hospital Facilities Usual, Reasonable and Customary to the selected Medical Maximum

Hospice Facilities Usual, Reasonable and Customary to the selected Medical Maximum

Skilled Nursing Facilities Usual, Reasonable and Customary to the selected Medical Maximum to a maximum of 30 days per Period of Coverage.

Home Health Care Services Usual, Reasonable and Customary to the selected Medical Maximum to a maximum of 30 days per Period of Coverage.

Part B Coverage

Physician and Surgeon Benefit Usual, Reasonable and Customary to the selected Medical Maximum

INSURING CLAUSE Certain Underwriters at Lloyd’s, London, herein referred to as “the Company” hereby insures all persons whose Application has been Approved, by Seven Corners, Inc., herein referred to as “the Administrator” on behalf of the Company and whose name is identified on the ID Card and/or recorded with the Administrator, subject to all of the Exclusions, Limitations and Provisions as set forth herein and in the Certificate of Insurance issued by the Company. Coverage is afforded only with respect to the named Insured Person(s), Coverage, amounts and limits specified herein and as identified in the Schedule of Benefits for the Insurance requested on the Application and for which the specified Premium has been paid to the Administrator.

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PLAN DEFINITIONS The term “Accident” or “Accidental” shall mean an event, independent of Illness(es) or self-inflicted means, which is the direct cause of bodily Injury(ies) to an Insured Person(s). The term “Administrator” shall mean Seven Corners, Inc. or Seven Corners Administrators, Inc., the organization contracted with the Company to provide underwriting, administrative and claims payment services under this Certificate. The term “Certificate” shall mean the summary of the terms of Coverage, which includes this document, the Insured Person(s)’s Application and any endorsements or amendments that will attach during the Insured Person(s)’s Period of Coverage. The term “Coinsurance” shall mean the percentage amount of Eligible Benefits, after the Deductible, which is the responsibility of each Insured Person(s) and must be paid by each Insured Person(s), before benefits under this Certificate are payable by the Company. The term “Company” shall mean Certain Underwriters at Lloyd’s, London, the organization providing the Coverage under this Certificate. The term “Congenital” shall mean a physical abnormality or condition that is present at birth, whether inherited or caused by the environment.

The term “Coverage Period” or “Period of Coverage” shall mean the period between the Individual Effective Date of Coverage and the Individual Termination Date of Coverage for this Certificate, which is stated on the Insured Person(s)’s ID Card. The term “Deductible” shall mean the amount of Eligible Benefits which are the responsibility of each Insured Person(s) and must be paid by each Insured Person(s), before benefits under this Certificate are payable by the Company. The Deductible amount is stated on the ID Card and/or in the Schedule of Benefits.

The term “Disablement” (as used with respect to medical expenses) shall mean an Illness or an Accidental bodily Injury necessitating Medical Treatment by a Physician.

The term “Eligible Benefits” shall mean expenses which are for Medically Necessary services, supplies, care, or Treatment(s); due to Illness(es) or Injury(ies); prescribed, performed or ordered by a licensed Physician(s) and/or Service Provider; Reasonable and Customary charges; incurred by the Insured Person(s) during their Period of Coverage; and which are (1.) listed in the Schedule of Benefits, (2.) not excluded in the Exclusions and (3.) do not exceed the maximum limits stated in the Schedule of Benefits. The term “Emergency” shall mean a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person’s life or limb in danger if medical attention is not provided within 24 hours.

The term “Home Health Care Agency” shall mean a public or private agency or one of its subdivisions, which operates pursuant to law; is regularly engaged in providing Home Nursing Care under the supervision of a Registered Nurse; maintains a daily record on each patient; and provides each patient with a planned program of observation and Treatment(s) by a Physician(s), in accordance with existing standards of medical practice.

The term “Home Health Care” shall mean services provided by a Home Health Care Agency and supervised by a Registered Nurse, which are directed toward the personal care of a patient; provided always that such care is in lieu of Medically Necessary Inpatient care in a Hospital. The term “Hospice” shall mean a coordinated plan of home, Inpatient and Outpatient care which provides palliative and supportive medical and other health services to terminally ill patients. An interdisciplinary team provides a program of planned and continuous care, of which the medical components are under the direction of a Physician(s). Care will be available 24 hours a day, seven days a week. The Hospice must meet the licensing requirements of the locality in which it operates. The term “Hospital” shall mean a place that 1.) is legally operated for the purpose of providing medical care and Treatment(s) to Sick or Injured persons for which a charge is made that the Insured Person(s) is legally obligated to pay in the absence of insurance 2.) provides such care and Treatment(s) in medical, diagnostic, or surgical facilities on its premises, or those prearranged for its use; 3.) provides 24-hour nursing service under the supervision of a Registered Nurse at all times; and 4.) operates under the supervision of a staff of one or more Physician(s). Hospital also means a place that is accredited as a Hospital by the Joint Commission on Accreditation of Hospitals, American Osteopathic Association, or the Joint Commission on Accreditation of Heath Care Organizations (JCAHO).

Hospital does not mean:

-a Convalescent, nursing, or rest home or facility, or a home for the aged; -a place mainly providing Custodial, Educational, or Rehabilitative Care; or -a facility mainly used for the Treatment(s) of drug addicts or alcoholics.

The term “Ill” or “Illness(es)” shall mean Sickness or Disease(s) of any kind listed in the most recent edition of the International Classification of Disease(s) ICD-9-CM, which is the required reporting tool for all diagnoses and Disease(s) to all U.S. Public Health Service and Health Care Financing Administration programs.

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The term “Injury(ies)” shall mean bodily Injury(ies) listed in the most recent edition of the International Classification of Disease(s) ICD-9-CM, which is the required reporting tool for all diagnoses and Disease(s) to all U.S. Public Health Service and Health Care Financing Administration programs and caused solely and directly by Accidental, external, and visible means occurring while this Certificate is in force and resulting directly and independently of all other causes resulting in a Covered Event(s) under this Certificate.

The term “Inpatient” shall mean a person who is confined in an institution for a period of twenty-four (24) hours or more and is charged for room and board.

The terms “Insured” or “Insured Person” shall mean a person eligible for benefits under the policy who has applied for coverage and is named on the application and for whom the Company has accepted premium.

The term “Medically Necessary” or “Medical Necessity” shall mean services, Treatment(s) or supplies received by the Insured Person(s) that are determined by the Company to be: 1.) appropriate and necessary for the symptoms, diagnosis, or direct care and Treatment(s) of the Insured Person(s)'s medical conditions; 2.) within the standards the organized medical community deems good medical practice for the Insured Person(s)'s condition; 3.) not provided solely for educational purposes or primarily for the convenience of the Insured Person(s), the Insured Person(s)'s Physician(s) or another Service Provider or person; 4.) not Experimental / Investigational and/or for Research; and 5.) not excessive in scope, duration, or intensity to provide safe and adequate, and appropriate Treatment(s). For Hospital stays, this means that acute care as an Inpatient is necessary due to the kinds of services the Insured Person(s) is receiving or the severity of the Insured Person(s)'s condition, in that safe and adequate care cannot be received as an Outpatient or in a less intensified medical setting. The fact that any particular Physician(s) may prescribe, order, recommend, or approve a service, Treatment(s), supply or level of care, does not of itself, make such Treatment(s) Medically Necessary or make the charge a Covered Expense(s) under this Certificate.

The term “Medicare” shall mean as defined under the Health Insurance for the Aged Act, Subchapter XVIII of the Social Security Amendments of 1965 as then constituted or later amended (42 U.S.C. 1395 et seq.)

The term “Mental Illness” shall mean Mental, emotional, and psychiatric disorders, Illness(es) or conditions (whether organic or non-organic, whether biological, non-biological, genetic, chemical or non-chemical in origin). Mental and nervous disorders include, but are not limited to psychoses; neurotic disorders; bipolar disorders; affective disorders; personality disorders; psychological or behavioral abnormalities, associated with transient or permanent dysfunction of the brain or related neurohomonal systems; and disorders, conditions, and Illness(es) listed in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders IV-R or the most recent edition of the International Classification of Disease(s) ICD-9-CM, which is the required reporting tool for all diagnoses and Disease(s) to all U.S. Public Health Service and Health Care Financing Administration programs on the date the medical care or Treatment(s) is rendered to an Insured Person(s).

The term “Physician, Competent Medical Authority” shall mean an individual who is qualified to perform or prescribe surgical or manipulative treatment. A Physician must be recognized (licensed and chartered) by the state or country in which he or she is practicing, cannot be a relative of the Insured, and must practice within the scope of his or her license. Treatment of a sickness or accident must be within the knowledge or expertise of the physician. The term “Outpatient” shall mean a person who receives care in a Hospital or another institution, including; ambulatory surgical center; Convalescent/skilled nursing facility; or Physician(s)'s office, for an Illness(es) or Injury(ies), but who is not confined and is not charged for room and board. The term “Pre-existing Condition” shall mean any medical condition, sickness, Injury, Illness, disease, Mental Illness or Mental Nervous Disorder, regardless of the cause including any congenital, chronic, subsequent, or recurring complications or consequences related thereto or resulting therefrom that with reasonable medical certainty existed at the time of application or any time during the 12 months prior to the effective date of coverage under this Certificate, whether or not previously manifested, symptomatic, known, diagnosed, treated or disclosed. This specifically includes but is not limited to any medical condition, sickness, Injury, Illness, disease, Mental Illness or Mental Nervous Disorder, for which medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent person would have sought treatment during the 12 month period immediately preceding the effective date of coverage under this Certificate. The term “Reasonable and Customary” shall mean the maximum amount that the Company determines is Reasonable and Customary for Eligible Benefits the Insured Person(s) receives, up to but not to exceed charges actually billed. The Company's determination considers: 1.) Amounts charged by other Service Providers for the same or similar service in the medical community where the services were received; 2.) Any unusual medical circumstances requiring additional time, skill or experience; 3.) The cost to the Service Provider of providing the services or supplies or performing the procedure; and 4.) Other factors the Company determines are relevant, including but not limited to, a resource based relative value scale. The term “Service Provider” shall mean a Hospital, Hospice, Convalescent/skilled nursing facility, ambulatory surgical center, psychiatric Hospital, community mental health center, residential treatment facility, psychiatric treatment facility, alcohol or drug dependency treatment center, birthing center, Physician(s), Dentist, chiropractor, licensed medical practitioner, nurse, medical laboratory, assistance service company, air/ground ambulance firm, or any other such facility that the Company approves to provide services under the Certificate. The term “Subjective Pain” shall mean an alleged pain for which there is no detectable cause and which is not supported by medical findings, physiological abnormality, trauma or injury, disease, or viral invasion as a cause thereof.

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The term “Skilled Nursing Facility” shall mean an institution which recognizes and utilizes professional methods, and is under the direction and supervision of a licensed Registered Nurse with care provided by a licensed Registered Nurse (RN), Licensed Practical Nurse (LPN), or a Licensed Vocational Nurse (LVN) on a 24-hour basis. Custodial care is not covered. The term “Sound Natural Tooth” shall mean a tooth that is whole and without impairment, periodontal or other conditions; is not more susceptible to Injury than a virgin tooth, and is not in need of the treatment provided for any reason other than Accidental Injury. A tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or Treated by endodontics, is not a Sound Natural Tooth. The term “Surgery(ies)” or “Surgical Procedure” shall mean an invasive diagnostic procedure; or the Treatment(s) of Illness(es) or Injury(ies) by manual or instrumental operations performed by a Physician(s) while the patient is under general or local anesthesia. The term “Terrorism” shall mean an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorism can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorism can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s). The term “Underwriter, Our, We Us” shall mean Certain Underwriters at Lloyd’s, London. The term “You or Your” shall mean the Primary Insured Person and the Primary Insured’s Spouse or Dependent. Eligibility Requirements:

For all Applicants/Insured Person(s): Insured Person(s) must not be eligible for the United States Medicare System. He or she must be at least sixty (60) years old and have not yet reached their ninety-sixth (96th) birthday to begin Coverage on this plan. As long as the Effective Date of Coverage is before the applicant’s 96th birthday, he/she may continue this policy after his/her 96th birthday. This plan is not available for U.S. citizens. If you become a U.S. citizen this coverage shall immediately terminate.

It is the Insured Person(s)’s responsibility to maintain all records regarding residence history, age and provide any documents to the Administrator, which would verify the Eligibility Requirements.

Period of Coverage: The minimum Period of Coverage is five (5) days, the maximum Period of Coverage is three hundred and sixty-four (364) days.

Continuation of Coverage (when applicable) A continuation of coverage option is available to You if Your initial Period of Coverage is less than three hundred and sixty four (364) days. If You require coverage beyond Your initial Period of Coverage, You may extend Your Period of Coverage but may not exceed three hundred and sixty four (364) days in total from Your original effective date. Your original effective date will be used to calculate Your Deductible and Coinsurance and to determine any Pre-existing conditions. Prior to Your expiration date, Seven Corners will send a renewal notice to your e-mail address, providing you with the opportunity to extend coverage. A $5.00 Administrative Fee will be included on each renewal notice. Description of Benefits: We will reimburse benefits listed below and as shown in the Schedule of Benefits and on the ID Card, subject to the terms and limitations of this certificate. The plan contains a deductible which must be satisfied before any benefits begin. After the deductible, Eligible Benefits will be paid at 80% for the next $10,000. After the deductible and coinsurance have been satisfied, benefits shall be paid at 100% of Eligible Benefits to the plan maximum as described in the Schedule of Benefits. PART A-HOSPITALIZATION BENEFITS (When the option has been selected and the applicable premium has been paid.) Covered expenses under Part A include: Semi-private room and board charges, general nursing, miscellaneous hospital services and supplies, drugs, x-rays, laboratory tests and operating room expenses. Benefits are applicable to the following facilities and as described:

Hospital Facilities Benefits include standard hospitalization and emergency treatments. Hospice Facilities A physician must certify the need of such care. Eligible Benefits include out-patient treatment. Skilled Nursing Facilities Qualification requires a medically necessary hospital confinement of three days or longer, must begin within thirty days following hospital confinement, and must be recommended and authorized by a treating physician. There is a 30 day maximum limit per Perod of Coverage. Home Health Care Services Skilled care at home is covered if such care is deemed medically necessary. There is a 30 day maximum limit per Perod of Coverage.

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PART B-PHYSICIAN AND SURGEONS BENEFITS (When the option has been selected and the applicable premium has been paid.) The costs of physicians and surgeons are covered on either an in-patient or out-patient basis. Supplies, therapy and ambulance services are covered if prescribed as medically necessary.

Conditions and Understandings 1) Benefits are paid directly to you to reimburse you for eligible medical expenses which have been paid by you, unless we agree to pay the provider directly. Unless and until we agree, this is a reimbursement certificate. 2) This certificate is issued on the basis of information given in the application. A copy of the application becomes a part of the certificate. 3) Material misstatement or concealment of health information made by or on behalf of you may render the insurance null and void. 4) Notice of claim is to be given at the earliest possible date, up to 90 days from the incident date. 5) Benefits shall be paid for all Eligible Benefits which are necessarily incurred due to an Illness manifesting itself or an accidental bodily injury occurring during the period of insurance. 6) These benefits are available only if there is no other source of funding available through any government insurance or private programs.

INTERNATIONAL TRAVEL COVERAGE An insured person may travel to additional countries, other than the United States. International travel coverage does not extend after your current expiration date. LIMITATIONS: Expenses which have limitations include: Alzheimer’s disease is limited to a lifetime maximum benefit of $25,000. Cardiac and/or Cancer related conditions are limited to a maximum benefit of $25,000 during the first one hundred and eighty (180) days of coverage. After 180 days, benefits will be paid as for any other condition. Cataract surgery and procedures are limited to a maximum benefit of $2,000. Dental (as a result of an accident) is limited to $500 per accident. Skilled Nursing Facilities are limited to a 30 day maximum per Period of Coverage. Home Health Care coverage is limited to a 30 day maximum per Period of Coverage. International Travel Coverage is limited to a Period of Coverage maximum of $5,000 for ages 60-74. For ages 75-95 the maximum is limited to $2,500.

Exclusions:

1. Any Pre-existing Condition(s) as defined herein; 2. Charges for Treatment(s) of the following Illness(es) or Surgery(ies), which Manifest(ed) themselves or are recommended, or symptoms

occur during the first one hundred and eighty (180) days of Coverage hereunder beginning on the initial Effective Date: any condition of the breast, any condition of the prostate, disorders of the reproductive system, gall stones or kidney stones, any acne diagnosis or acne related condition, or any Surgery(ies) that is not Emergency in nature, as Emergency is defined hereunder. Note: Coverage for such Illness(es) or Surgery(ies) may be further limited under the Pre-Existing Condition exclusion and definition contained herein, or other exclusions contained herein;

3. Injury(ies) or Illness(es) that is not presented to the Company for payment within ninety (90) days immediately following the Incident, which gave rise to the expenses;

4. Services, supplies or treatment, including any period of Hospital confinement, which were not recommended, approved and certified as Medically Necessary and reasonable by a Physician;

5. Any elective surgery 6. Any type of expense for which payment was made by Medicare or any other private or public program; 7. Charges for Treatment which exceeds Reasonable and Customary charges; 8. Outpatient drugs 9. Expenses as a result of or in connection with intentionally self-inflicted Injury or Illness while sane or insane; 10. Treatment in connection with alcohol usage and drug addiction, or use of any drug or narcotic agent; allergies and/or

Mental and Nervous disorders, rest cures; quarantine or isolation; 11. Cosmetic or plastic Surgery, except as the result of a covered Accident; for the purposes of this plan, treatment of a deviated nasal septum

shall be considered a cosmetic condition; 12. Dental care, except as the result of Injury to Sound Natural Tooth caused by Accident; 13. Injury sustained while taking part in mountaineering, hang gliding, parachuting, bungee jumping, zip lining, racing of any kind, snowmobiling,

motorcycle/motor scooter riding (whether as passenger or driver), scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, snow skiing and snowboarding, luge, paragliding, motocross, Moto X, and any sport or athletic activity which is undertaken for thrill seeking and exposes the insured to abnormal or extreme risk of injury and/or is in violation of applicable laws, rules, or regulations.

14. Vocational, occupational, speech, recreational, or music therapy; 15. Eye refractions or eye examinations for the purpose of prescribing corrective lenses for eyeglasses or for the fitting thereof 16. Treatment and the provision of false teeth or dentures, normal ear tests and the provision of hearing aids;

ATR15-150929-01GC (09/28/2015) 10

17. Vaccinations, inoculations, routine physicals or other examinations where there are no objective indications of impairment in normal health, and laboratory diagnostic or x-ray examinations, except in the course of a Covered Event(s) established by a prior call or attendance of a Physician(s),

18. Coverage outside of the United States boundaries, except as payable under the International Travel Coverage benefit 19. War, hostilities or warlike operations (whether war be declared or not), Invasion, Act of an enemy foreign to the nationality of the insured

person or the country in, or over, which the act occurs, Civil war, Riot, Rebellion, Insurrection, Revolution, Overthrow of the legally constituted government, Civil commotion assuming the proportions of, or amounting to, an uprising, Military or usurped power, Explosions of war weapons, Utilization of Nuclear, Chemical or Biological weapons of mass destruction howsoever these may be distributed or combined, Murder or Assault subsequently proved beyond reasonable doubt to have been the act of agents of a state foreign to the nationality of the insured person whether war be declared with that state or not, Terrorist activity. For the purpose of this Exclusion;

i. Terrorist activity means an act, or acts, of any person, or group(s) of persons, committed for political, religious, ideological or similar purposes with the intention to influence any government and/or to put the public, or any section of the public, in fear. Terrorist activity can include, but not be limited to, the actual use of force or violence and/or the threat of such use. Furthermore, the perpetrators of terrorist activity can either be acting alone, or on behalf of, or in connection with any organization(s) or governments(s).

ii. Utilization of Nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission, discharge, dispersal, release or escape of fissile material emitting a level of radioactivity capable of causing incapacitating disablement or death amongst people or animals.

iii. Utilization of Chemical weapons of mass destruction means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing incapacitating disablement or death amongst people or animals.

iv. Utilization of Biological weapons of mass destruction means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) micro-organism(s) and/or biologically produced toxin(s) (including genetically modified organisms and chemically synthesized toxins) which are capable of causing incapacitating disablement or death amongst people or animals.

Also excluded hereon is any Loss or expense of whatsoever nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, or suppressing any, or all, of the situations described above. In the event any portion of this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect;

20. Expenses as a result of or in connection with the commission of a criminal or felony offense; 21. Expenses for or resulting from Subjective Pain. 22. Treatment(s) for Chronic Fatigue Syndrome, including but not limited to diagnostic workups; 23. Injury sustained while participating in professional athletics, including but not limited to the event, games, practice, conditioning and any other

activity related to professional athletics. 24. Injury sustained while participating in amateur or interscholastic athletics, including but not limited to the event, games, practice, conditioning

and any other activity related to amateur or interscholastic athletics; this exclusion does not apply to non-competitive, recreational or intramural activities. Note: A sponsored and/or organized Amateur or Interscholastic Athletic event includes training camps, team sports, or any formal grouping of people participating in one or multiple events that may/may not require a fee for participation.

25. Purchase or rental of durable medical equipment outside of a Hospital, including but not limited to wheelchairs, oxygen tanks and walkers; 26. Congenital abnormalities and conditions arising out of or resulting therefrom; 27. Injury and/or illnesses resulting or arising from being under the influence of alcohol, chemicals, or drugs, other than drugs taken in accordance

with Treatment(s) prescribed and directed by a Physician(s), but not for the Treatment of substance abuse; and injury or illness resulting from operating any type of vehicle after consuming any alcohol, chemicals, or drugs

28. Expenses incurred after You have become eligible for Medicare; 29. Expenses incurred after You have become a U.S. citizen.

ATR15-150929-01GC (09/28/2015) 11

CERTIFICATE PROVISIONS: Entire Contract; Changes: The Certificate, including the Application, Schedule of Benefits, Exclusionary Rider(s), endorsements and the attached papers, if any, constitutes the entire contract of Insurance. No change in the Certificate shall be valid until Approved by an executive officer of the Administrator and unless such Approval is endorsed hereon. No agent has authority to change this Certificate or to waive any of its provisions. Notice of Claim: Written notice of claim must be given to the Company within ninety (90) days after the occurrence or commencement of any Covered Event(s) covered by the Certificate. If Notice cannot be given within ninety (90) days because of incapacity or some similar reason, it must be given as soon thereafter as is reasonably possible. Notice given by or on behalf of the claimant to the Administrator, or to any authorized agent of the Company, with the name of the Insured Person(s) and the Certificate Number on the ID Card to identify the Insured Person(s) shall be deemed notice to the Company. Claim Forms: The Company, upon receipt of a Notice of Claim, will furnish to the claimant such forms as are usually furnished by it for filing Proofs of Loss. If such forms are not furnished within fifteen (15) days after the giving of such notice, the claimant shall be deemed to have complied with the requirements of the Certificate as to Proof of Loss upon submitting, within the time fixed in the Certificate for filing Proofs of Loss, written proof covering the occurrence, the character and the extent of the Covered Event(s) for which claim is made. Proof of Loss: Written Proof of Loss must be furnished to the Administrator, at its said office, within ninety (90) days after the date of such Covered Event(s). Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible. In any case, the proof required must be given no later than one year from the time specified except in the absence of legal capacity. The Company at its option may pend resolution and adjudication of submitted claims and/or deny coverage for Proof of Loss submitted thereafter, or for incomplete Proof of Loss and/or failure to submit Proof of Loss. Payment of Claims: Subject to any written direction of the Insured Person(s) which is submitted within the time for filing the Proof of Loss, all or a portion of any indemnities provided by this Certificate for Hospital, nursing, medical or Surgical service may, at the Company's option, be paid directly to the Hospital or Service Provider rendering such services. Physical Examination and Autopsy: The Underwriter at its own expenses shall have the right and opportunity to examine the person of any individual whose Injury or Illness is the basis of claim when and as often as it may reasonably require during the pendency of a claim hereunder and to make an autopsy in case of death, where it is not forbidden by law. Effective Date of Individual Insurance: After review and Approval of each Applicant by the Administrator, Coverage will become effective on the later of the following dates: (1.) The date requested on the Application, (2.) The date the appropriate Premium and Application are received by the Administrator, or (3.) The date the Applicant is Approved by the Administrator. The Insured’s ID Card will state the official Effective Date of Coverage, as issued by the Administrator. Termination Date of Individual Insurance: Coverage will terminate upon the earlier of the following: (1.) The end of the period for which Premium has been paid, (2.) The date the Insured Person(s) fails to meet the Eligibility Requirements described in SECTION 3. (3.) The date the Company cancels Coverage for a specific Class(es) of Insured Person(s), in which the individual Insured Person(s) may be included. This certificate will automatically cease upon your eligibility for the United States Medicare System. It is your responsibility to enroll in Medicare when you are first eligible. Not in Lieu of Worker's Compensation: This Insurance is not in lieu of and does not affect any requirements for Coverage by Worker's Compensation Insurance. Certificate of Insurance: The Company shall issue to each Insured Person(s) an individual Certificate of Insurance, which shall state the essential features of Insurance to which such person is entitled and to whom benefits are payable, if required to do so by the laws of the state in which the Insured Person(s) resides when his Insurance becomes effective. Data Furnished by Insured Person(s) or Applicant(s): Insured Person(s) or Applicant(s) shall furnish all information requested on the Application and/or Claim Form and any additional information requested by the Company. The refusal or failure of the Insured Person(s)’s Relative, Employer, Insurance Company, Physician(s), Hospital or Service Provider to make all medical reports and records available to the Company could cause an otherwise valid claim or Application to be denied or the file to be closed due to lack of or limited reply from the above referenced individuals and entities. Failure on the part of the Insured Person(s) to maintain adequate documentation regarding travel history could cause an otherwise valid claim (where travel history is material to the benefit and claim) to be denied or the file to be closed. The Company has the option whether or not to consider medical information provided by friends / Relatives of the Insured Person(s) as valid for underwriting or claim administration. Cancellation: The Company may cancel an entire Class(es) of Insured Persons based upon claims experience in a certain region or within a gender/age category. NOTWITHSTANDING anything contained in this Insurance to the contrary, this Insurance may be cancelled by the Insured Person at any time by written notice or by surrendering of this Certificate of Insurance. This Insurance may also be cancelled by or on behalf of the

ATR15-150929-01GC (09/28/2015) 12

Company by delivering to the Insured Person or by mailing to the Insured Person, by registered, certified or other first class mail, at the Insured Person’s address as shown in this Insurance, written notice stating when, not less than ten (10) days thereafter, the cancellation shall be effective. The mailing of notice as aforesaid shall be sufficient proof of notice and this Insurance shall terminate at the date and hour specified in such notice. Payment or tender of any Unearned Premium by the Company shall not be a condition precedent to the effectiveness of Cancellation but such payment shall be made as soon as practicable. If the period of limitation relating to the giving of notice is prohibited or made void by any law controlling the construction thereof, such period shall be deemed to be amended so s to be equal to the minimum period of limitation permitted by such law. Excess Benefits: All Coverage shall be in excess of all other valid and collectible insurance and shall apply only when such benefits are exhausted. Other valid and collectible insurance for which benefits may be payable are insurance programs provided by: 1.) Individual, group or blanket insurance or coverage; 2.) Other prepayment coverage provided on a group or individual basis; 3.) Any coverage under labor management trustee plans, union welfare plans, employer organizational plans, employee benefit organization plans, or other arrangement of benefits for individuals of a group; 4.) Any coverage required or provided by any statute, socialized insurance program; or 5.) Any no-fault automobile insurance; 6.) Any third party liability insurance. Subrogation: The Company has the right to full subrogation and reimbursement of any and all amounts paid by the Company to or on behalf of, an Insured Person(s), if the Insured Person(s) receives any sum of money from any person, plan or legal entity which is legally obligated to make payments arising out of any act or omission of any person whether a third party or another covered person under the Certificate, which directly or indirectly caused a physical or mental condition, in connection with which payment of any benefits under the Certificate to, or on behalf of, such Insured Person(s) was made. The Certificate shall have a lien against such sum of money received from third parties or other persons described above or their insurers, or the insurer of the Insured Person(s), and shall be reimbursed there from. The Insured Person(s) further agrees to notify other persons described above in writing, of the Certificate's subrogation and lien rights before the receipt of any payment from said parties or other persons. The Insured Person(s) shall be responsible for all expenses of recovery from such parties or other persons, including but not limited to, all attorneys' fees incurred in collection of such payments or payments by other persons, which fees and expenses shall not reduce the amount of reimbursement to the Certificate required of the Insured Person(s). The Insured Person(s) agrees to reimburse the Certificate for any benefit paid hereunder, out of any monies recovered from such party or other persons as a result of judgment, settlement or otherwise, even though such monies are not characterized as amounts paid for medical expenses or claims. The Insured Person(s) agrees to furnish such information and assistance, and to execute and deliver all necessary instruments, as the Company or its designee may request to facilitate the enforcement of these subrogation rights, including but not limited to the execution of a subrogation agreement prior to payments of benefits under the Certificate to, or on behalf of the Insured Person(s). The Insured Person(s) shall not release or discharge any party from his or her obligation to the Insured Person or the Certificate or take any other action, which could impair the Certificate's subrogation rights. The Certificate's exercise of its rights, to take whatever action it sees fit against any third party or other persons, shall not affect the Insured Person(s)'s right to pursue other forms of recovery. If the Insured Person(s), or any one acting on his or her behalf, has not taken action to pursue his or her rights against such parties or other persons to obtain a judgment, settlement or other recovery, the Company or its designee, upon giving thirty (30) days written notice to the Insured Person(s) shall have the right to take such action in the name of the Insured Person(s) to recover that amount of benefits paid under the Certificate; provided, however, that any action taken without the consent of the Insured Person(s) shall be without prejudice to such Insured Person(s). The Certificate's right to reimbursement as set forth herein shall be payable first from sums received from the parties or other persons and such reimbursement shall continue until the Insured Person(s)'s obligations hereunder to the Certificate are fully discharged, even though the Insured Person(s) does not receive full compensation or recovery for his/her Injury(ies), damages loss or debt. This right to subrogation shall exist in all cases. If an Insured Person(s) fails to comply with these requirements, the Insured Person(s) shall not be eligible to receive any benefits, services or payments under the Certificate until there is compliance, regardless of whether such benefits are related to the act or omission of such party or other persons. Monetary Limits: The monetary limits stated in this Certificate and the Premium shall be in United States dollars. For services outside of the territorial limits of the United States, the exchange rate used to determine the amount of United States dollars to be paid is the exchange rate effective for the date the claims expense was incurred. Assignment: The Insurance provided hereunder is not assignable, but benefits may be assigned in accordance with the, Payment of Claims provision.

ATR15-150929-01GC (09/28/2015) 13

Modification of Medical Condition Prior to Issuance of Certificate: Any conditions, which Manifest(ed) themselves between the date the Application is signed and the date the Coverage is issued, shall be considered Pre-Existing and not covered for the entire Certificate Period. Additionally, some conditions, which Manifest(ed) themselves between the date the Application is signed and the date the Coverage is issued, may affect your eligibility for Insurance. Incontestability: After two (2) years from the Effective Date of Individual Insurance, only fraudulent misstatements in the Application may be used to Void the Certificate or deny any claim for Loss, Eligible Benefits or disability starting after the two (2) year period. Representations in Application: Any statement or description made by or on behalf of the Insured Person(s) on the Application for Insurance Coverage is a representation and is not a warranty. A misrepresentation, omission, concealment of fact, or incorrect statement may prevent recovery under the Certificate only if any of the following apply; a.) the misrepresentation, omission, concealment, or statement is fraudulent or is material either to the Approval of the Coverage for the Insured Person(s) or payment of otherwise Eligible Benefits by the Company, b.) if the Administrator or Company had known the facts prior to issuance of Coverage, the Administrator or Company would not have issued Coverage, would not have issued Coverage at the same Premium, or would have issued an Exclusionary Rider(s) to the Coverage under this Certificate. Patient Support: To ensure that Medically Necessary services, supplies and Treatment(s) are provided in the most cost effective and appropriate manner, the Company may determine that a particular claim or diagnosis occurring under this Insurance may be placed under the patient support program. Once the Insured Person(s) follows the Pre-Certification requirement and the Company determines that the condition (or diagnosis) qualifies for the patient support requirement, the Company will advise the Insured Person(s) that a Patient Support Specialist will be assigned to the Insured Person(s) for that particular condition. From that point forward, the Company’s Patient Support Specialist may make recommendations of alternative Treatment(s) in the form of other locations, other procedures, or other supplies that can be used that are more appropriate and/or cost effective for both the Insured Person(s) and the Company (and will result in the same or better care). The Insured Person(s) and the Insured Person(s)’s Physician(s) will have input in this evaluation. Should the recommendations be accepted by the Insured Person(s), the Insured Person(s) agrees to hold the Company harmless and the Company shall not be held liable or otherwise responsible for any Treatment(s), service, supply, procedure or care provided to the Insured Person(s) except for the payment of benefits under this Insurance. After the Insured Person(s) has been notified that the condition meets the Patient Support program requirements, the Company reserves the right to: a. Generate payment for Treatment(s), services, and/or supplies which are excluded under this Insurance that would be beneficial to the Insured Person(s) and cost effective to the Company; and b. Decline payment for expenses that would otherwise be covered under this Insurance that exceed the amount the Company would have paid had the Insured Person(s) followed the recommended Treatment(s) program established by the patient support program. Complaints: Any initial inquiry or complaint should be addressed to the Administrator, as defined herein. If the Insured Person(s) is not satisfied with the manner in which an inquiry or complaint has been managed by the Administrator, the Insured Person(s) may request in writing to the Complaints & Advisory Department at Lloyd's to review the case without prejudice to your rights in law. Complaints and Advisory Department of Lloyd's 1 Lime Street London EC3M 7HA United Kingdom Patient Protection and Affordable Care Act: This insurance is not subject to, and does not provide certain insurance benefits required by the

United States Patient Protection and Affordable Care Act (“PPACA”). The insurance benefits provided by this policy are stated in your policy

documents and do not include any additional benefits required by the PPACA. The PPACA requires certain U.S. residents and citizens to obtain

PPACA compliant insurance coverage. In certain circumstances penalties may be imposed on U.S. residents and citizens who do not maintain

PPACA compliant insurance coverage. You should consult your attorney, insurance agent, or tax professional to determine if the PPACA's

requirements are applicable to you.

Refund of Premium Certain Underwriters at Lloyds, London realizes that there is uncertainty in international travel. Refund of total plan cost will only be considered if written request is received by the Administrator prior to the Effective Date of Coverage. If written request is received after the Effective Date of Coverage, the unused portion of the Plan cost may be refunded minus a cancellation fee, provided no claim has been submitted to the Administrator for reimbursement.

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Pre-Certification Requirements

The following expenses must always be Pre-certified:

Inpatient care

Any Surgery or Surgical Procedure

Computerized Tomography (CAT Scan)

Magnetic Resonance Imaging (MRI) To comply with the Pre-certification requirements, You must: 1. Contact Seven Corners Assist at the telephone number shown below and on your ID Card as soon as possible before the expense is to be incurred; and 2. Comply with Seven Corners Assist’s instructions and submit any information or documents they require; and 3. Notify all Physicians, Hospitals and other providers that this insurance contains Pre-certification requirements and ask them to fully cooperate with Seven Corners. Emergency Pre-certification – In the event of an Emergency Hospital admission, Pre-certification must be made within 48 hours after the admission, or as soon as is reasonably possible. If You comply with the Pre-certification requirements, and the expenses are Pre-certified, the Company will pay Eligible Medical Expenses subject to all terms, conditions, provisions and exclusions herein. If You do not comply with the Pre-certification requirements or if the expenses are not Pre-certified: 1. Eligible Medical Expenses will be reduced by 50%; and 2. The Deductible will be subtracted from the remaining amount; and 3. The Coinsurance will be applied. Pre-certification Does Not Guarantee Benefits – The fact that expenses are Pre-certified does not guarantee coverage for, or payment of the service or procedure reviewed. Eligibility for and payment of benefits are subject to all the terms, conditions, provisions and exclusions herein. Concurrent Review – For Inpatient stays of any kind, the Administrator will Pre-certify a limited number of days of confinement. Additional days of Inpatient confinement may later be Pre-certified if an Insured receives prior approval.

Network Procedures Inside of the United States: Seven Corners’ provider network is not required. By utilizing the network, You may receive potential discounts and out-of-pocket savings for any incurred eligible expenses.

Utilizing the network does not guarantee benefits or that the treating facility will bill Seven Corners direct.

Contact information for Seven Corners Assist is provided below and on the back of Your virtual ID Card. Our multilingual representatives are available 24/7 to help you. A listing of network providers can be found at www.sevencorners.com/networkproviders or by contacting Seven Corners Assist. In addition, WellAbroad.com provides a complete listing of providers as well as other important and varied up-to-date travel information.

Seven Corners Assist Inside the United States: 1-800-690-6295 Outside the United States: 0-317-818-2808 (Collect) Fax: 1-317-815-5984 E-mail: assist@sevencorners.com

Wellabroad.com In our ever changing world, Seven Corners’ WellAbroad® seeks to prepare individuals and groups with the advanced tools for successful travel. WellAbroad® offers medical, political and cultural information and includes many benefits and educational resources, such as:

• Text messaging alerts - Registered users receive updates regarding weather emergencies, security issues, custom alerts, and health care or pandemic warnings.

• Provider network directory - Clients and travelers can create customized country profiles which allow instant access to providers in the specified regions to which they are traveling.

• Online forums - Fellow travelers and Seven Corners’ staff post experiences and travel tips which can be accessed at any time.

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Claims Services Important Note: Claim forms and receipts for medical expenses must be sent to Seven Corners quickly. Claim submissions must be made within

ninety (90) after the Date of Service. Should they be received after ninety (90) days, they may be considered ineligible.

To report claims or verify eligibility, send the original bills and claim forms to Seven Corners, Inc., or call or fax to the numbers below. Be certain to include Your Certificate Number shown on the ID Card with all correspondences:

Seven Corners, Inc.

303 Congressional Blvd; Carmel, IN 46032 800-335-0477 or 317-575-2256 FAX 317-575-2659 email: info@sevencorners.com www.Seven Corners.com

Insurance Underwriter

This Insurance, under Certificate: ATR15-150929-01GC, is underwritten by Certain Underwriters at Lloyd’s, London, rated “A” (Excellent) by AM Best.

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Appendix A - COORDINATION OF BENEFITS AND SERVICES Purpose of This Provision An Insured Person(s) may be covered for health benefits or services by more than one plan. If he/she is, this provision allows the Company to coordinate what the Company pays or provides with what another Plan pays or provides. This provision sets forth the rules for determining which is the primary plan and which is the secondary plan. Coordination of benefits is intended to avoid duplication of benefits while at the same time preserving certain rights to coverage under all Plans under which the Insured Person(s) is covered. DEFINITIONS The words shown below have special meanings when used in this provision. Please read these definitions carefully. Allowable Expense: The charge for any health care service, supply, or other item of expense for which the Insured Person(s) is liable when the health care service, supply, or other item of expense is covered at least in part under any of the Plans involved, except where a statute requires another definition, or as otherwise stated below. When this Certificate is coordinating benefits with a Plan that provides benefits only for dental care, vision care, prescription drugs or hearing aids, Allowable Expense is limited to like items of expense. The Company will not consider the difference between the cost of a private hospital room and that of a semi-private hospital room as an Allowable Expense unless the stay in a private room is Medically Necessary and Appropriate. When this Certificate is coordinating benefits with a Plan that restricts coordination of benefits to a specific coverage, the Company will only consider corresponding services, supplies or items of expense to which coordination of benefits applies as an Allowable Expense. Claim Determination Period: A Calendar Year, or portion of a Calendar Year, during which an Insured Person(s) is covered by this Certificate and at least one other Plan and incurs one or more Allowable Expense(s) under such plans. Plan: Coverage with which coordination of benefits is allowed. Plan includes:

a) Group insurance and group subscriber contracts, including insurance continued pursuant to a Federal or State continuation law; b) Self-funded arrangements of group or group-type coverage, including insurance continued pursuant to a Federal or State continuation

law; c) Group or group-type coverage through a health maintenance organization (HMO) or other prepayment, group practice and individual

practice plans, including insurance continued pursuant to a Federal or State continuation law; d) Group hospital indemnity benefit amounts that exceed $150 per day; e) Medicare or other governmental benefits, except when, pursuant to law, the benefits must be treated as in excess of those of any private

insurance plan or non-governmental plan. Plan does not include:

a) Individual or family insurance contracts or subscriber contracts; b) Individual or family coverage through a health maintenance organization or under any other repayment, group practice and individual

practice plans; c) Group or group-type coverage where the cost of coverage is paid solely by the Insured Person(s) except when coverage is being

continued pursuant to a Federal or State continuation law; d) Group hospital indemnity benefit amounts of $150 per day or less; e) School accident type coverage; f) A State plan under Medicaid.

Primary Plan: A Plan whose benefits for an Insured Person(s)’s health care coverage must be determined without taking into consideration the existence of any other Plan. There may be more than one Primary Plan. A Plan will be the Primary Plan if either “a” or “b” below exists:

a) The Plan has no order of benefit determination rules or it has rules that differ from those contained in this Coordination of Benefits and Services provision; or

b) All Plans which cover the Insured Person(s) use order of benefit determination rules consistent with those contained in the Coordination of Benefits and Services provision and under those rules, the plan determines its benefits first.

Reasonable and Customary: An amount that is not more than the usual or customary charge for the service or supply as determined by the Company, based on a standard which is most often charged for a given service by a Provider within the same geographic area. Secondary Plan: A Plan which is not a Primary Plan. If an Insured Person(s) is covered by more than one Secondary Plan, the order of benefit determination rules of this Coordination of Benefits and Services provision shall be used to determine the order in which the benefits payable under the multiple secondary plans are paid in relation to each other. The benefits of each Secondary plan may take into consideration the benefits of the Primary Plan or Plans and the benefits of any other Plan which, under this Coordination of Benefits and Services provision, has its benefits determined before those of that Secondary Plan. PRIMARY AND SECONDARY PLAN The Company considers each plan separately when coordinating payments. The primary plan pays or provides services or supplies first, without taking into consideration the existence of a Secondary Plan. If a Plan has no coordination of benefits provision, or if the order of benefit determination rules differ from those set forth in these provisions, it is the primary plan. A secondary plan takes into consideration the benefits provided by a primary plan when, according to the rules set forth below, the plan is the secondary plan. If there is more than one secondary plan, the order of benefit determination rules determine the order among the secondary plans.

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The secondary plan(s) will pay up to the remaining unpaid allowable expenses, but no secondary plan will pay more than it would have paid if it had been the primary plan. The method the secondary plan uses to determine the amount to pay is set forth below in the Procedures to be Followed by the Secondary Plan to Calculate Benefits section of this provision. The secondary plan shall not reduce Allowable Expense for medically necessary and appropriate services and supplies on the basis that precertification, preapproval, notification or second surgical opinion procedures were not followed. RULES FOR THE ORDER OF BENEFIT DETERMINATION The benefits of the Plan that covers the Insured Person(s) as an employee, member, subscriber or retiree shall be determined before those of the Plan that covers the Insured Person(s) as a Dependent. The coverage as an employee, member, subscriber or retiree is the primary plan. The benefits of the Plan that covers the Insured Person(s) as an employee who is neither laid off nor retired, or as a dependent of such person, shall be determined before those for the Plan that covers the Insured Person(s) as a laid off or retired employee, or as such a person’s Dependent. If the other Plan does not contain this rule, and as a result the Plans do not agree on the order of benefit determination, this portion of this provision shall be ignored. The benefits of the Plan that covers the Insured Person(s) as an employee, member, subscriber or retiree, or Dependent of such person, shall be determined before those of the Plan that covers the Insured Person(s) under a right of continuation pursuant to Federal or State law. If the other Plan does not contain this rule, and as a result the Plans do not agree on the order of benefit determination, this portion of this provision shall be ignored. If a child is covered as a Dependent under Plans through both parents, and the parents are neither separated nor divorced, the following rules apply:

a) The benefits of the Plan of the parent whose birthday falls earlier in the Calendar Year shall be determined before those of the parent whose birthday falls later in the Calendar Year.

b) If both parents have the same birthday, the benefits of the Plan which covered the parent for a longer period of time shall be determined before those of the parent for a shorter period of time.

c) Birthday, as used above, refers only to month and day in a calendar year, not the year in which the parents was born. d) If the other plan contains a provision that determines the order of benefits based on the gender of the parent, the birthday rule in this

provision shall be ignored. If a child is covered as a Dependent under Plans through both parents, and the parents are separated or divorced, the following rules apply:

a) The benefits of the Plan of the parent with custody of the child shall be determined first. b) The benefits of the Plan of the spouse of the parent with custody shall be determined second. c) The benefits of the Plan of the parent without custody shall be determined last. d) If the terms of a court decree state that one of the parents is responsible for the health care expenses for the child, and if the entity

providing coverage under that Plan has knowledge of the terms of the court decree, then the benefits of that plan shall be determined first. The benefits of the plan of the other parent shall be considered as secondary. Until the entity providing coverage under the plan has knowledge of the terms of the court decree regarding health care expenses, this portion of this provision shall be ignored.

If the above order of benefits does not establish which plan is the primary plan, the benefits of the Plan that covers the employee, member or subscriber for a longer period of time shall be determined before the benefits of the Plan(s) that covered the person for a shorter period of time. Procedures to be Followed by the Secondary Plan to Calculate Benefits In order to determine which procedure to follow it is necessary to consider:

a) The basis on which the primary plan and the secondary plan pay benefits; and b) Whether the provider who provides or arranges the services and supplies is in the network of either the primary plan or the secondary

plan. Benefits may be based on the Usual and Customary Charge (U&C), or some similar term. This means that the provider bills a charge and the Insured person(s) may be held liable for the full amount of the billed charge. In this section, a Plan that bases benefits on a Usual and Customary Charge is called a “U&C Plan.” Benefits may be based on a contractual fee schedule, sometimes called a negotiated fee schedule or some similar term. This means that although a provider, called a network provider, bills a charge, the Insured person(s) may be held liable only for an amount up to the negotiated fee. In this section, a Plan that bases benefits on a negotiated fee schedule is called a “Fee Schedule Plan.” If the Insured person(s) uses the services of a non-network provider, the plan will be treated as a U&C Plan even though the plan under which he or she is covered allows for a fee schedule. Payment to the provider may be based on a capitation. This means that the health maintenance organization (HMO) pays the provider a fixed amount per Insured Person(s). The Insured Person(s) is liable only for the applicable deductible, coinsurance, or copayment. If the Insured person(s) uses the services of a non-network provider, the HMO will only pay benefits in the event of emergency care or urgent care. In this section, a Plan that pays providers based upon capitation is called a “Capitation Plan.” In the rules below, “provider” refers to the provider who provides or arranges the services or supplies, and “HMO” refers to a health maintenance organization plan. Primary Plan is U&C Plan and Secondary Plan is U&C Plan The secondary plan shall pay the lesser of:

a) The difference between the amount of the billed charges and the amount paid by the primary plan; or b) The amount the secondary plan would have paid if it had been the primary plan.

When the benefits of the secondary plan are reduced as a result of this calculation, each benefit shall be reduced in proportion, and the amount paid shall be charged against any applicable benefit limit of the plan. Primary Plan is Fee Schedule Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in both the primary plan and the secondary plan, the Allowable Expense shall be the fee schedule of the primary plan. The secondary plan shall pay the lesser of:

a) The amount of any deductible, coinsurance or copayment required by the primary plan; or

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b) The amount the secondary plan would have paid if it had been the primary plan. The total amount the provider receives from the primary plan, the secondary plan and the Insured Person(s) shall not exceed the fee schedule of the primary plan. In no event shall the Insured Person(s) be responsible for any payment in excess of the copayment, coinsurance or deductible of the secondary plan. Primary Plan is U&C Plan and Secondary Plan is Fee Schedule Plan If the provider is a network provider in the secondary plan, the secondary plan shall pay the lesser of:

a) The difference between the amount of the billed charges for the Allowable Charges and the amount paid by the primary plan; or b) The amount the secondary plan would have paid if it had been the primary plan.

The Insured Person(s) shall only be liable for the copayment, deductible, or coinsurance under the secondary plan if the Insured Person(s) has no liability for copayment, deductible or coinsurance under the primary plan and the total payments by both the primary and secondary plans are less than the provider’s billed charges. In no event shall the Insured Person(s) be responsible for any payment in excess of the copayment, coinsurance or deductible of the secondary plan. Primary Plan is Fee Schedule Plan and Secondary Plan is U&C Plan If the provider is a network provider in the primary plan, the Allowable Expense considered by the secondary plan shall be the fee schedule of the primary plan. The secondary plan shall pay the lesser of:

a) The amount of any deductible, coinsurance or copayment required by the primary plan; or b) The amount the secondary plan would have paid if it had been the primary plan.

Primary Plan is Fee Schedule Plan and Secondary Plan is U&C Plan or Fee Schedule Plan If the primary plan is an HMO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Insured Person(s) receives from a non-network provider is not considered as urgent care or emergency care, the secondary plan shall pay benefits as if it were the primary plan. Primary Plan is Capitation Plan and Secondary Plan is Fee Schedule Plan or U&C Plan If the Insured Person(s) receives services or supplies from a provider who is in the network of both the primary plan and the secondary plan, the secondary plan shall pay the lesser of:

a) The amount of any deductible, coinsurance or copayment required by the primary plan; or b) The amount the secondary plan would have paid if it had been the primary plan.

Primary Plan is Capitation Plan or Fee Schedule Plan or U&C Plan and Secondary Plan is Capitation Plan If the Insured Person(s) receives services or supplies from a provider who is in the network of the secondary plan, the secondary plan shall be liable to pay the capitation to the provider and shall not be liable to pay the deductible, coinsurance or copayment imposed by the primary plan. The Insured Person(s) shall not be liable to pay any deductible, coinsurance or copayments of either the primary plan or the secondary plan. Primary Plan is an HMO and Secondary Plan is an HMO If the primary plan is an HMO plan that does not allow for the use of non-network providers except in the event of urgent care or emergency care and the service or supply the Insured Person(s) receives from a non-network provider is not considered as urgent care or emergency care, but the provider is in the network of the secondary plan, the secondary plan shall pay benefits as if it were the primary plan.

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SEVERABILITY OF INTEREST CLAUSE This policy shall operate in all respects as if a separate policy had been issued to each party insured hereunder, except that in no event shall the

total liability of the Insurers in respect of all parties insured hereunder exceed the Limit of Indemnity stated in this policy. - LSW1001

LLOYD'S PRIVACY POLICY STATEMENT UNDERWRITERS AT LLOYD'S, LONDON The Certain Underwriters at Lloyd's, London want You to know how we protect the confidentiality of Your non-public personal information. We want You to know how and why we use and disclose the information that we have about You. The following describes our policies and practices for securing the privacy of our current and former customers. INFORMATION WE COLLECT The non-public personal information that we collect about You includes, but is not limited to: Information contained in applications or other forms that You submit to us, such as name, address, and social security number Information about Your transactions with our affiliates or other third-parties, such as balances and payment history c) Information we receive from a consumer-reporting agency, such as credit-worthiness or credit history INFORMATION WE DISCLOSE We disclose the information that we have when it is necessary to provide our products and services. We may also disclose information when the law requires or permits us to do so, CONFIDENTIALITY AND SECURITY Only our employees and others who need the information to service Your account have access to Your personal information. We have measures in place to secure our paper files and computer systems. RIGHT TO ACCESS OR CORRECT YOUR PERSONAL INFORMATION You have a right to request access to or correction of Your personal information that is in our possession. CONTACTING US If You have any questions about this privacy notice or would like to learn more about how we protect Your privacy, please contact the agent or broker who handled this insurance. We can provide a more detailed statement of our privacy practices upon request. - LSW1135b

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One Lime Street London EC3M 7